Biafine ConsentBiafine Topical Emulsion:Biafine Topical Emulsion is a water based emulsion formulated for the dressing and management of superficial wounds, minor abrasions, dermal ulcers, donor sites, first and second-degree burns, including sunburns, and radiation dermatitis. When applied properly to a wound, Biafine Topical Emulsion provides an optimum moist environment for the healing process.Indications and Usage:Biafine Topical Emulsion is indicated as a wound dressing for: Superficial Wounds Minor Abrasions Leg Ulcers First and second-degree burns, including sunburns Donor Sites For dermal ulcers, including full thickness wound and pressure sores, consult a physician Radiation DermatitisConsent* I have read and understoodContraindications:Biafine Topical Emulsion is contraindicated for use on skin rashes related to food or medicine allergies, or when an allergy to one of the ingredients is known.Warnings:In radiation therapy, Biafine Topical Emulsion may be applied as directed by the treating physician. Do not apply four hours prior to a radiation session. Keep out of reach of small children. Precautions:For the treatment of any dermal wound consult your physician. Use Biafine Topical Emulsion only as directed. Biafine Topical Emulsion is non-toxic, it is for topical use only and should not be ingested or taken internally. If ingested or taken internally, contact the doctor or poison control center immediately. Biafine Topical Emulsion does not contain a sunscreen and should not be used prior to extended exposure to the sun. The use of Biafine Topical Emulsion on skin rashes due to allergies has not been studied sufficiently and therefore is not recommended. Do not use on bleeding wounds until the bleeding has stopped. Following the application of Biafine Topical Emulsion a temporary tingling sensation may occur for 10 to 15 minutes. If the condition does not improve within 10 to 14 days, consult your physician. If clinical signs of infection are present, appropriate treatment should be initiated. If clinically indicated, use of Biafine Topical Emulsion may be continued during the anti-infective therapy. Biafine Topical Emulsion may dissolve fuchsin when this dye is used to define the margins of the radiation fields to be treated.Consent* I have read and understoodInstructions for Use:Biafine Topical Emulsion is for topical use only as directed by a healthcare professional.Wounds, abrasions, full thickness wound and donor site management:Wash the affected areas with saline, clean water, or a suitable wound cleanser. Apply Biafine Topical Emulsion on and around the affected areas in thick layers ¼ to ½ inch thick. If applying gauze dressing, moisten the dressing lightly before application. Reapply Biafine Topical Emulsion as described above every 24 to 48 hours or as directed until the wound or lesion has healed fully. For donor site management, apply Biafine Topical Emulsion after skin removal and cover with the moist dressing. Leave for seven days. Reapply as directed.First and second-degree burns, including sunburns:Before application of Biafine Topical Emulsion to burns, take precaution in removing any clothing in the affected areas. Apply Biafine Topical Emulsion as soon as possible on and around the affected areas, and a ¼ to ½ inch layer until the skin no longer absorbs the product. A white waxy residue may remain. If pain from the burn persists apply thinner layers of Biafine Topical Emulsion until the pain has ceased. Continue to apply Biafine Topical Emulsion until the affected area(s) has healed completely. Application of Biafine Topical Emulsion to the affected areas should continue during any subsequent physical therapy treatments.Radiation dermatitis:Apply a generous amount of Biafine Topical Emulsion three times per day seven days a week to the treated areas, gently massaging the areas until Biafine Topical Emulsion is completely absorbed. Biafine Topical Emulsion may be applied as indicated by the treating physician (see warnings). Continue to apply Biafine Toical Emulsion as described above until the skin has fully recovered. Do not interrupt applications during the course of radiation therapy, even for one day. Do not apply Biafine Topical Emulsion four hours prior to a radiation session.Consent* I have read and understoodIngredients:Biafine Topical Emulsion contains purified water, liquid paraffin, ethylene glycol monostearate, stearic acid, propylene glycol, paraffin wax, squalene, avocado oil, trolamine-sodium alginate, triethanolamine, cetyl palmitate, methylparaben (sodium salt), sorbic acid (potassium salt), propylparaben (sodium salt), and fragrance.Consent* I have read and fully understand the above, received satisfactory answers to my questions and had a chance to discuss alternative treatments.Patient's Name* First Last Email Address* Phone*Date* Date Format: MM slash DD slash YYYY Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.